Hand Hygiene:

June 1, 2006

Article

A WAR IS BEING waged against infectious agents, with newly energized efforts on both a domestic and a global front to boost hand-hygiene compliance. On the domestic front, the Institute for Healthcare Improvement (IHI), the originator of the 100,000 Lives Campaign, has released the publication Improving Hand Hygiene: A Guide for Improving Practices Among Health Care Workers. Recognizing a worldwide need to improve hand hygiene in healthcare facilities, the World Health Organization (WHO) launched its Guidelines on Hand Hygiene in Health Care (advanced draft) in October 2005. These global consensus guidelines reinforce the need for multidimensional strategies as the most effective approach to promote hand hygiene. Key elements include staff education and motivation, adoption of an alcohol-based hand rub as the primary method for hand hygiene, use of performance indicators, and strong commitment by all stakeholders, such as front-line staff, managers and healthcare leaders, to improve hand hygiene. The formalized guidelines are scheduled to be issued in 2007.

The IHIs guidance document was prepared in collaboration with the Centers for Disease Control and Prevention (CDC), the Association for Professionals in Infection Control and Epidemiology (APIC), and the Society of Healthcare Epidemiology of America (SHEA). The purpose of this guidance document is to help organizations reduce healthcare-associated infections (HAIs), including infections due to antibiotic-resistant organisms, by improving hand hygiene practices and use of gloves among healthcare workers (HCWs).

HAIs are a significant cause of morbidity and mortality among hospitalized patients worldwide, and can affect nearly 2 million individuals annually in the United States, causing as many as 80,000 deaths annually. According to the IHI guidance document, transmission of healthcare-associated pathogens most often occurs via the contaminated hands of HCWs. Accordingly, hand hygiene (i.e., handwashing with soap and water or use of a waterless, alcohol-based hand rub) has long been considered one of the most important infection control measures for preventing HAIs. However, compliance by HCWs with recommended hand hygiene procedures has remained unacceptable, with compliance rates generally below 50 percent of hand-hygiene opportunities. Many factors have contributed to poor handwashing compliance among healthcare workers, including a lack of knowledge among personnel about the importance of hand hygiene in reducing the spread of infection and how hands become contaminated, lack of understanding of correct hand hygiene technique, understaffing and overcrowding, poor access to handwashing facilities, irritant contact dermatitis associated with frequent exposure to soap and water, and lack of institutional commitment to good hand hygiene.

To overcome these barriers, the CDCs Healthcare Infection Control Practices Advisory Committee (HICPAC) published a comprehensive Guideline for Hand Hygiene in Health-Care Settings in 2002. One of the principal recommendations of this guideline was that waterless, alcohol-based hand rubs are the preferred method for hand hygiene in most situations due to the superior efficacy of these agents in rapidly reducing bacterial counts on hands and their ease of use. Alcohol preparations also rapidly kill many fungi and viruses that cause HAIs. The guideline recommended that healthcare facilities develop multidimensional programs to improve hand hygiene practices.

Wearing gloves during patient care is an additional intervention to help reduce transmission of infectious agents in high-risk situations. Gloves protect patients by reducing contamination of the HCWs' hands and subsequent transmission of pathogens to other patients. In addition, when gloves are worn in compliance with the CDCs Standard Precautions, gloves protect HCWs from exposure to bloodborne infections such as HIV and hepatitis B and C. However, gloves must be used properly. Gloves can become contaminated during care and must be removed or changed when moving from a contaminated site to a clean site on the same patient. Gloved hands can also become contaminated due to tiny punctures in the glove material or during glove removal; therefore, hand hygiene must be performed immediately after glove removal. Consequently, use of gloves is an important adjunct to, but not a replacement for, proper hand hygiene practice.

Numerous studies have suggested that hand hygiene compliance can be improved, at least modestly, by a variety of interventions, introduction of alcohol-based hand rub, and educational and behavioral initiatives. Most authorities believe that multidimensional interventions are more effective. For example, Pittet et al. implemented a multidisciplinary, multimodal hand hygiene improvement program featuring promotion of alcohol-based hand rub and achieved substantial improvement in hand hygiene compliance. Much of the improvement in compliance was attributed to increased use of the alcohol-based hand rub. As hand hygiene compliance improved, both the incidence of nosocomial infections and new methicillin-resistant Staphylococcus aureus (MRSA) cases decreased, although the authors did not assert that they had rigorously demonstrated a causal link.

The IHI advocates in its guidance document a hand hygiene intervention package, which is a group of best practices that individually improve care, but when applied together should result in substantially greater improvement. The science supporting each intervention is sufficiently established to be considered a standard of care.

According to the IHI, the following four components of the hand hygiene intervention package are critical aspects of a multidimensional hand hygiene program. Glove use is included in this package because proper glove use is inextricably linked to effective hand hygiene.

1. Clinical staff, including new hires and trainees, understand key elements of hand hygiene practice (demonstrate knowledge)Â

2. Clinical staff, including new hires and trainees, use appropriate technique when cleansing their hands (demonstrate competence)Â

3. Alcohol-based hand rub and gloves are available at the point of care (enable staff)Â

4. Hand hygiene is performed at the right time and in the right way, and gloves are used appropriately as recommended by CDCs Standard Precautions (verify competency, monitor compliance, and provide feedback)Â

These steps are now explored in more detail:

1. Clinical staff, including new hires and trainees, understand key elements of hand hygiene practice (demonstrate knowledge): HCWs hands can become contaminated by touching the body secretions, excretions, nonintact skin, and wounds of patients; however, they can also become contaminated by touching intact skin of patients and environmental surfaces in the immediate vicinity of the patients. HCWs should demonstrate accurate knowledge that their hands can become contaminated during all of these activities.

Compared to handwashing, alcohol-based hand rubs have been shown to be more effective in reducing the number of viable bacteria and viruses on hands, require less time to use, can be made more accessible at the point of care, and cause less hand irritation and dryness with repeated use. Handwashing is required when hands are visibly contaminated and is also appropriate after caring for patients with diarrhea, including patients with Clostridium difficile-associated diarrhea, before eating, and after use of the restroom. Healthcare workers should demonstrate accurate knowledge of the advantages of the use of hand rubs in most situations as well as the specific indications for handwashing.

2. Clinical staff, including new hires and trainees, use appropriate technique when cleansing their hands (demonstrate competency): To be optimally effective, an appropriate volume of alcohol-based hand rub or soap must be applied to all surfaces of the hands and fingers for a sufficient length of time. Failure to do so will reduce the efficacy of the hand hygiene regimen. Accordingly, clinical staff should demonstrate competency in performing hand hygiene correctly. Competent hand rubbing requires that a sufficient volume of an alcohol-based rub is applied to cover all surfaces of the hands and fingers and that at least 15 seconds of rubbing is necessary before the hands are dry. Competent handwashing requires that a sufficient volume of soap is applied to cover all surfaces of the hands and fingers, and that at least 15 seconds of scrubbing with friction is performed before rinsing. Care should be taken to avoid contamination of hands after handwashing (paper towels or single-use cloth towels should be used; if the faucet is hand-operated, the towel should be used to turn of the spigot).

3. Alcohol-based hand rub and gloves are available at the point of care: Placing alcohol-based hand rub dispensers near the point of care has been associated with increased compliance by HCWs with recommended hand hygiene procedures. For example, Bischoff et al. found that compliance by HCWs was significantly greater when dispensers for alcohol-based hand rub were adjacent to each patients bed than when there was only one dispenser for every four beds. In critical care, availability of alcohol-based hand rub at the point of care proved to minimize the time constraint associated with hand hygiene during patient care and to predict better compliance. In a study of hand hygiene among physicians, Pittet et al. found that easy access to an alcohol-based hand rub was an independent predictor of improved hand hygiene compliance. Availability of alcohol-based products at the point of care should be supplemented by availability of gloves in appropriate sizes for use in the high-risk situations described previously for which barrier technique is indicated. Sterile gloves are not required for this purpose; studies have shown that clean single-use gloves have negligible numbers of non-pathogenic microorganisms when cultured.

4. Hand hygiene is performed and gloves are used appropriately as recommended by CDCs Standard Precautions: Clinical staff should clean their hands according to recommendations listed in the CDCs Guideline for Hand Hygiene in Health-Care Settings. Clinical staff should also wear gloves according to recommendations listed in CDCs Standard Precautions.

In its guidance document, the IHI recommends specific steps to take toward achieving improvement on hand-hygiene compliance in healthcare organizations, including taking a multi-disciplinary team approach to improving hand hygiene among HCWs. Improvement teams should be heterogeneous in make-up, but unified in mindset. The value of bringing diverse personnel together is that all members of the care team are given a stake in the outcome and work together to achieve the same goal. Including all stakeholders in the process to implement proper hand hygiene techniques will help gain buy-in and cooperation of all parties. For example, according to the IHI, teams without nurses are bound to fail. Teams led by nurses and therapists may be successful, but often lack leverage; physicians must also be part of the team. The team should include, at a minimum, an administrator or senior leader who can help remove barriers to implementation, as well as a member of the department that supplies hand hygiene agents to clinical areas. Involve the team in designing or selecting hand hygiene posters or other motivational and educational materials. Some suggestions for attracting and retaining excellent team members include: using data to defi ne and solve the problem; finding champions and opinion leaders within the hospital to lend the effort immediate credibility; and engaging individuals who want to work on the project rather than trying to convince those who do not.

The IHI guidance document says that commitment of institutional leadership is a key determinant of success. There must be alignment of leadership, including the board, executives, heads of clinical departments, and the infection control team. Leadership should give encouragement, set expectations, remove barriers, and celebrate success. Concrete, raisethe- bar goals set the stage for achieving rates of compliance well beyond historical levels. An all-or-none mentality for compliance (i.e., performing all elements of good practice) is necessary to achieve the highest possible levels of reliable performance. From the patients perspective, compliance with all elements of appropriate hand hygiene and glove practice is a reasonable expectation. Once high levels of compliance are achieved, a process owner must be identified; in other words, the person who will ensure that high levels of performance are maintained and help to troubleshoot key aspects of the hand hygiene program if the compliance rate falls.

The IHI guidance document emphasizes that dramatic improvement requires setting clear aims and quantitative time-specific improvement targets. An organization will not improve without a fi rm commitment and measurable goals. Teams are more successful when they have unambiguous, focused aims. Setting numerical goals clarifies the aims, creates tension for change, directs measurement, and focuses initial changes. Once aims have been established, the team needs to be careful not to back away from the aims deliberately or drift away unconsciously. Appropriate resources and personnel time must be allocated to achieve raise-the-bar targets. An example of an appropriate aim for improving hand hygiene compliance can be as modest as, Increase hand hygiene compliance by 25 percent within one year. However, more aggressive targets are desirable.

Consistent with the Joint Commission on the Accreditation of Healthcare Organization (JCAHO)s National Patient Safety Goal No. 7, a raise-the-bar aim would be to improve hand hygiene compliance to greater than 90 percent. This latter goal helps change the focus from hand hygiene as a laudable practice to hand hygiene as a mandatory procedure. Regardless of the exact numeric target, the aim should be endorsed completely and enthusiastically by institutional leadership and opinion leaders.

As we have seen, the WHO Guidelines on Hand Hygiene in Health Care (advanced draft) will be issued as a final version in 2007. According to WHO, these guidelines will be pilot-tested and it is likely that changes will be made to some of the technical content of the chapters in light of pilot test results.

Didier Pittet, director of the infection control program at the University of Geneva Hospitals in Switzerland and leader of the Global Patient Safety Challenge World Alliance for Patient Safety of the World Health Organization, states HAIs affect hundreds of millions of patients worldwide every year. As an unintended result of seeking care, these infections lead to more serious illness, prolong hospital stays, and induce long-term disability. Not only do they inflict unexpected high costs on patients and their families, they also lead to a massive additional fi nancial burden on the healthcare system and last but not least contribute to unnecessary patient deaths. Pittet adds, Hand hygiene is the primary measure to reduce infections. Though the action is simple, the lack of compliance among healthcare providers is problematic throughout the world.

Hand hygiene is an important part of the overall set of goals of the Global Patient Safety Challenge 2005-2006 Clean Care is Safer Care initiative, which strives to address HAIs and provide an effective vehicle for improvement. In May 2004, the 57th World Assembly of the WHO supported the creation of an international alliance to improve patient safety and make it a global initiative. In October 2004, the World Alliance for Patient Safety was launched, and HAIs became one of the initiatives priorities.

A prevalence survey conducted under the auspices of WHO in 55 hospitals of 14 countries representing four WHO regions revealed that, on average, 8.7 percent of hospital patients suffer nosocomial infections.

At any time, more than 1.4 million people worldwide suffer from infectious complications associated with healthcare. According to the WHO guidelines, in developed countries, about 5 percent to 10 percent of patients admitted to acute-care hospitals acquire an infection that was not present or incubating on admission. These HAIs add to the morbidity, mortality, and costs that would be expected from the patients underlying disease alone. In the United States, 1 in 136 hospital patients becomes seriously ill as a result of acquiring an infection in hospital.

According to the WHO guidelines, Most patient deaths and suffering attributable to HAIs can be prevented. Low-cost and simple practices already exist to prevent these infections. Hand hygiene, a very simple action, remains the primary measure to reduce HAIs and the spread of antimicrobial resistance, enhancing patient safety across all settings. Yet compliance with hand hygiene is very low throughout the world and governments should ensure that hand hygiene promotion receives enough attention and funding to succeed. Knowledge of measures to prevent HAIs has been widely available for years. Unfortunately, for a number of reasons, preventive measures are often not being used. Poor training and adherence to proven practices on hand hygiene is one reason.

Failure to apply infection control measures is the leading cause of the spread of infectious agents. The WHO guidelines comment, This spread may be particularly important during outbreaks, and healthcare settings can act as multipliers of disease, with an impact on both hospital and community health. The emergence of life-threatening infections such as severe acute respiratory syndrome (SARS), viral hemorrhagic fevers (Ebola and Marburg viral infections), and the risk of a new influenza pandemic highlight the urgent need for efficient infection control practices in healthcare. The guidelines note that uneven application of policies and practices across countries is another concern, as usage may vary largely between hospitals and countries. This variation was reflected during the SARS pandemic, in which the proportion of healthcare workers affected ranged from 20 percent to 60 percent of cases worldwide.

According to the WHO guidelines, factors influencing adherence to recommended hand hygiene practices include:

1. Observed risk factors for poor adherence:

Working in intensive careÂ

Working during the week (vs. weekend)Â

Wearing gowns/glovesÂ

Automated sinkÂ

Activities with high risk of cross-transmissionÂ

Understaffing or overcrowdingÂ

High number of opportunities for hand hygiene per hour of patient careÂ

Nursing assistant status (rather than a nurse)Â

Physician status (rather than a nurse)Â

2. Self-reported factors for poor adherence:

Handwashing agents cause irritations and drynessÂ

Sinks are inconveniently located or shortage of sinksÂ

Lack of soap, paper, towelÂ

Often too busy or insufficient timeÂ

Patient needs take priorityÂ

Hand hygiene interferes with healthcare worker/patient relationshipÂ

Low risk of acquiring infection from patientsÂ

Wearing of gloves or belief that glove use obviates the need for hand hygieneÂ

Lack of knowledge of guidelines and protocolsÂ

Not thinking about it, forgetfulnessÂ

No role model from colleagues or superiorsÂ

Skepticism about the value of hand hygieneÂ

Disagreement with the recommendationsÂ

Lack of scientific information of definitive impact of improved hand hygiene on HAI ratesÂ

3. Additional perceived barriers to appropriate hand hygiene:

Lack of active participation in hand hygiene promotion at individual or institutional levelÂ

Lack of role model for hand hygieneÂ

Lack of institutional priority for hand hygieneÂ

Lack of administrative sanction of noncompliers/rewarding of compliersÂ

Lack of institutional safety climate /Â

The advanced draft of the WHO guidelines may be found at: http:// www.who.int/patientsafety/events/hand_hygiene/en/Â

Bibliography:

Jarvis WR. Selected aspects of the socioeconomic impact of nosocomial infections: Morbidity, mortality, cost, and prevention. Infect Control Hosp Epidemiol. 1996 Aug;17(8):552-557.

Pittet D, Mourouga P, Perneger TV. Compliance with handwashing in a teaching hospital. Ann Intern Med. 1999;130:126-130.

Lankford MG, Zemblower TR, Trick WE, Hacek DM, Noskin GA, Peterson LR. Infl uence of role models and hospital design on hand hygiene of healthcare workers. Emerg Infect Dis. 2003;9:217-23.

Pittet D, Boyce JM. Hand hygiene and patient care: Pursuing the Semmelweis legacy. Infect Dis. 2001;1:9-20.

Boyce JM, Pittet D, et al. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Morbid Mortal Wkly Rep.Â 2002;51(RR16):1-45.

WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft): A Summary. World Health Organization; 2005. Available online at http://www.who.int/patientsafety/events/05/HH_en.pdfÂ Â

Pittet D, et al. Bacterial contamination of the hands of hospital staff during routine patient care. Arch Intern Med. 1999;159:821-826.

Pessoa-Silva CL, Richtmann R, Calil et al. Dynamics of bacterial hand contamination during routine neonatal care. Infect Control and Hosp Epidemiol. 2004;25:192-197.

Tenorio AR, Badri SM, Sahgal NB, et al. Effectiveness of gloves in the prevention of hand carriage of vancomycin-resistant Enterococcus species by health care workers after patient care. Clin Infect Dis. 2001; 32:826-829.

Johnson S, Gerding DN, et al. Prospective, controlled study of vinyl glove use to interrupt Clostridium difficile nosocomial transmission. Am J Med. 1990;88:137-140.

Garner JS, Hospital Infection Control Practices Advisory Committee. Guideline for isolation precautions in hospitals. Infect Control Hosp Epidemiol. 1996;17:53-80. Available online at http://www.cdc.gov/ncidod/dhqp/gl_isolation.htmlÂ Â

Pittet D, Hugonnet S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet. 2000;356:1307-1312.

Pittet D, Dharan S, Touveneau S, Savan V, Perneger TVl. Bacterial contamination of the hands of hospital staff during routine patient care. Arch Intern Med. 1999;159:821-826.

Duckro AN, Blom DW, Lyle EA, Weinstein RA, Hayden MKl. Transfer of vancomycinresistant enterococci via healthcare worker hands. Arch Intern Med. 2005;165:302-307.

Larson EL, Eke PI, Wilder MP, Laughon BE. Quantity of soap as a variable in handwashing. Infect Control. 1987;8:371-375.

Widmer AE, Dangel M. Alcohol-based hand rub: Evaluation of technique and microbiological efficacy with international infection control professionals. Infect Control Hosp Epidemiol. 2004;25:207-209.

Bischoff WE, Reynolds TM, Sessler CN, Edmond MB, Wenzel RP. Handwashing compliance by healthcare workers: The impact of introducing an accessible, alcohol-based hand antiseptic. Arch Intern Med. 2000;160: 1017-1021.

Hugonnet S, Perneger TV, Pittet D. Alcohol-based hand rub improves compliance with hand hygiene in intensive care units. Arch Int Med. 2002;162:1037-1043.

Pittet D, Simon A, Hugonnet S, et al. Hand hygiene among physicians: Performance, beliefs, and perceptions. Ann Intern Med. 2004;148:1-8.

Hand Hygiene Case Studies

We asked readers of ICT to submit their case studies regarding efforts to boost handhygiene compliance, and we share some of the responses we received.

Natasha Usher, RN, BN, BSc,Â
reports that the infection prevention and control team working at the David Thompson Health Region in central Alberta, Canada, had initiated a hand hygiene campaign pilot project in two rural hospitals, Stettler and Sundre Hospitals, from January 2006 to April 2006. The basis of the pilot project was the distribution of hand-hygiene literature, social marketing literature, and innovative learning concepts. The focus of the project was behavior change, thus creating a hand hygiene compliance culture over time.

It consisted of multi-modal strategies such as posters, fact sheets, memos, buttons, banners, personal sized waterless hand sanitizer, door hangers, instructional hand hygiene strips, and a commercial, with three of four of these strategies used each month in each hospital. Focus groups were held once per month with representatives from frontline staff, where they chose materials for the campaign pilot, answered questions, and filled out a survey tool. In order to establish a baseline and measure the final outcome, a reformatted survey originally developed by hand hygiene expert Elaine Larson was used.

Jennifer Humphreys, RN,Â
occupational health and infection control manager at CarePartners Health Services in Asheville, N.C., reports that the infection control and quality departments developed a project called Partners in Your Health, targeting visitors, patients, and staff members. The campaign included:

Buttons worn by staff to remind them to wash their hands, and remind peers to do the sameÂ

Hand-antiseptic dispensers were installed in family and visitor waiting areas, and all entrances to the hospital campus had a sign that read, CarePartners expects our staff to practice good hand washing and hand hygiene. We encourage all of our visitors to do so as well. Please use the hand antiseptic available here; dispensers are also located outside of patient rooms.

A one-page letter identifying ways to prevent infection along with adhesive stickers of the prevention logo was included in admission packets; the letter recommended that patients and family members ask their healthcare providers if they have washed or sanitized their hands before they are provided care.

Caregivers were provided with neoprene-jacketed clip-on mini hand sanitizer bottles with the reminder, Clean Hands Prevent Infections

Keith R. Mason, RN, MPH, BSN, BA, CCRC,Â
describes a masters degree thesis, Project Hands, conducted in 1996: Handwashing compliance in a 600-bed teaching hospital was 21 percent;14 months later, after an ongoing interventional program, compliance was at 81 percent and sustained with minimal, ongoing interventions. The project called for the involvement of staff from the infection control, quality assurance/improvement, and nursing education departments, as well as a unit-specific quality assurance team member, and a hospital director/medical director.

Methods used in the project included rotating more than 30 different handwashing posters that provided cues to action, with new posters used every two weeks; the posters were placed in patient rooms, every sink location, every staff break room, and every restroom. The campaign also employed an education component, including Pathogen of the Week posters (explaining the basic epidemiology of common nosocomial organisms); two CEU courses on nosocomial infections offered for all shifts on all units; a monthly article on nosocomial infections in the hospital newsletter; a bi-monthly report on handwashing compliance rates on selected units, also in the hospital newsletter; and a mailing to all hospital staff. Covert handwashing observations were conducted, with the reporting of results to all levels of management; and to address the issues of skin integrity, a milder yet effective handwashing soap was introduced in all critical-care areas.

According to Mason, the lessons learned included:

Multiple approaches are more effective than single.

Educational materials need to be tailored to educational level.

Humorous posters are most receptive by staff.

Ongoing, low-level interventions are required for sustaining compliance.

Mild soaps and convenient dispenser placement is the most important factor in achieving compliance.

HCWs personal need /safety is a stronger motivator for compliance than patient safety.

Hand Hygiene:
New Initiatives on the Domestic and Global Fronts

By Kelly M. Pyrek